Working together as partners, the group, supported, co-designed and delivered by community leaders, practice clinicians and administrators and other external health and care partners, organise ‘Community Mobilisation’ workshops. The aim being to start a dialogue with the local hard to reach communities about health and wellbeing particularly for people affected by and living with diabetes.

The service model comprises of:

• The invitation (in their own language) to participate in a ‘Sympathy’ group-people like them supported by peers credentialised by clinicians
• A welcoming session at the practice over lunch-time (when those with family or work commitments were most available) with food provided by the group itself and a range of activities to try and provide an atmosphere of participation.
• Informal discussions between the group, supported by peers and professionals
• Structured education delivered on disease management and lifestyle appropriate to the understanding of the group, in a language appropriate and culturally sensitive
• Health checks provided by the practice clinicians facilitated by interpreters and in a relaxed and informal setting

GPs and clinicians, supported by the data identified a cohort of patients (Bangladeshi) with poor diabetic outcomes. Using researchers to work with individuals from this group, their families and community leaders it became clear that this group had poor health and well-being outcomes as a result of:

• The disease-diabetes is more prevalent in this ethnic group and many have a number of co-morbidities
• The older people in this group were primarily at risk
• They were more likely to be living in poverty, in poor housing, unemployed or in low-paid employment with long hours
• Services were not sensitive to their needs-language barriers, access hours, short appointments, lack of understanding of the need for checks and cultural shame around disease, lack of understanding how the health and care systems work

What the people themselves defined as important to them:

• They would like to understand their health and disease better and to know how to look after themselves-but this needed to be in a language and way that they could understand
• They needed to be able to access services at times and in ways that worked for them (many had family commitments or work hours that meant lunch-time was easier than mornings or evenings for example
• They had confidence in a clinical setting such as a GP surgery but found the usual consulting format intimidating and could often not understand what was said to them
• They would like to have more peer support and opportunities to look after their health and to do it with people like themselves-same age, understanding of cultural issues etc (for example around exercise) and to help them navigate often complex health and care services

From this project there have been the following outcomes/outputs (subject to formal evaluation):

• The engagement was excellent-people who had not services attended and the group bonded
• Feedback from service users and providers was universally positive
• Clinical checks were completed
• Cost effective delivery model
• Could be up-scaled and more widely used for other Long-term conditions